STUDENT NAME:  ____________________________________________________________ GRADE THIS YEAR:   __________    SEX:  ____________

CLASS NAME:    ___________________________________  DAY: __________________ TIME: ______________________________

RELIGION:      _______________________  SCHOOL:     _______________________ ETHNIC BACKGROUND:     _______________________

LANGUAGE:      _______________________  BIRTH DATE: ___/___/____            ATTENDED HERE BEFORE:  Y  N

HEALTH PROBLEMS:  _______________________________

OTHER CONDITIONS: _______________________________

REMARKS:          _______________________________

If the student is not living with his or her birth mother and/or birth father, please enter the following:

BIRTH FATHER: ______________________________________________       BIRTH MOTHER: ______________________________________________

ADDRESS:      ______________________________________________       ADDRESS:      ______________________________________________

CITY/STATE:   _________________ ZIP CODE:  _________________       CITY/STATE:   _________________ ZIP CODE:  _________________

HOME PHONE:   (___) ___________ BUS PHONE: (___) ___________       HOME PHONE:   (___) ___________ BUS PHONE: (___) ___________

RELIGION:     _________________ MAR STAT:  _________________       RELIGION:     _________________ MAR STAT:  _________________



STUDENT NAME:  ____________________________________________________________ GRADE THIS YEAR:   __________    SEX:  ____________

CLASS NAME:    ___________________________________  DAY: __________________ TIME: ______________________________

RELIGION:      _______________________  SCHOOL:     _______________________ ETHNIC BACKGROUND:     _______________________

LANGUAGE:      _______________________  BIRTH DATE: ___/___/____            ATTENDED HERE BEFORE:  Y  N

HEALTH PROBLEMS:  _______________________________

OTHER CONDITIONS: _______________________________

REMARKS:          _______________________________

If the student is not living with his or her birth mother and/or birth father, please enter the following:

BIRTH FATHER: ______________________________________________       BIRTH MOTHER: ______________________________________________

ADDRESS:      ______________________________________________       ADDRESS:      ______________________________________________

CITY/STATE:   _________________ ZIP CODE:  _________________       CITY/STATE:   _________________ ZIP CODE:  _________________

HOME PHONE:   (___) ___________ BUS PHONE: (___) ___________       HOME PHONE:   (___) ___________ BUS PHONE: (___) _________

RELIGION:     _________________ MAR STAT:  _________________       RELIGION:     _________________ MAR STAT:  _________________



STUDENT NAME:  ____________________________________________________________ GRADE THIS YEAR:   __________    SEX:  ____________

CLASS NAME:    ___________________________________  DAY: __________________ TIME: ______________________________

RELIGION:      _______________________  SCHOOL:     _______________________ ETHNIC BACKGROUND:     _______________________

LANGUAGE:      _______________________  BIRTH DATE: ___/___/____            ATTENDED HERE BEFORE:  Y  N

HEALTH PROBLEMS:  _______________________________

OTHER CONDITIONS: _______________________________

REMARKS:          _______________________________

If the student is not living with his or her birth mother and/or birth father, please enter the following:

BIRTH FATHER: ______________________________________________       BIRTH MOTHER: ______________________________________________

ADDRESS:      ______________________________________________       ADDRESS:      ______________________________________________

CITY/STATE:   _________________ ZIP CODE:  _________________       CITY/STATE:   _________________ ZIP CODE:  _________________

HOME PHONE:   (___) ___________ BUS PHONE: (___) ___________       HOME PHONE:   (___) ___________ BUS PHONE: (___) ___________

RELIGION:     _________________ MAR STAT:  _________________       RELIGION:     _________________ MAR STAT:  _________________